<!DOCTYPE html >
<html>

	<head>
		<meta http-equiv="Content-Type" content="text/html; charset=UTF-8" />
		<meta name="format-detection" content="telephone=no">
		<meta name="viewport" content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no">
		<title>浙商保险 - 填写投保信息</title>
		<link type="text/css" rel="stylesheet" href="css/style.css" />
		<link type="text/css" rel="stylesheet" href="css/caninfor.css" />
		<link rel="stylesheet" type="text/css" href="css/common.css">
		<link rel="stylesheet" type="text/css" href="css/city-picker.css">
		<script src="js/style.js"></script>
		<script type="text/javascript" src="js/jquery-1.9.1.js"></script>
		<script type="text/javascript" src="js/date.js"></script>
		<script type="text/javascript" src="js/iscroll.js"></script>
		<script type="text/javascript">
			$(function() {
				$('#beginTime').date();
				$('#endTime').date({
					theme: "datetime"
				});
			});
		</script>
		<script src="js/city-picker.data.js"></script>
		<script src="js/city-picker.js"></script>
	</head>

	<body>
		<div class="menages"><i></i>投保人信息</div>
		<div class="basic manager-div margin-b5">
			<div class="title_text">
				姓名
				<input type="text" value="请填写投保人姓名" onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
			<div class="title_text">
				身份证号
				<input type="text" maxlength="18" value="请填写身份证号 " onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
			<div class="title_text">
				电子邮箱
				<input type="text" value="请填写电子邮箱 " onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
			<div class="title_text">
				手机号码
				<input type="tel" maxlength="11" value="请填写手机号码 " onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
		</div>
		<div class="menages"><i></i>被保险人信息</div>
		<div class="basic manager-div margin-b5">
			<div class="title_text">
				与投保人关系
				<select name="rdate" class="select">
					<option selected="selected">本人</option>
					<option>其他</option>
				</select>
			</div>
			<div class="title_text">
				姓名
				<input type="text" value="请填写投保人姓名" onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
			<div class="title_text">
				身份证号
				<input type="text" maxlength="18" value="请填写身份证号" onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
			<div class="title_text">
				手机号码
				<input type="tel" maxlength="11" value="请填写手机号" onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
		</div>
		<div class="menages"><i></i>保单及发票寄送</div>
		<div class="basic manager-div margin-b5">
			<div class="title_text">
				发票、纸质保单
				<select name="rdate" class="select">
					<option>需要</option>
					<option>不需要</option>
				</select>
			</div>
			<div class="title_text">
				发票抬头
				<input type="text" value="请填写发票抬头" onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
			<div class="title_text">
				收件人
				<input type="text" value="请填写收件人" onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
			<div class="title_text">
				手机号码
				<input type="tel" maxlength="11" value="请填写手机号" onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
			<div class="title_text">
				邮寄省市
				<div class="city-city" id="distpicker">
					<div class="form-group">
						<div style="position: relative;">
							<input id="city-picker3" class="form-control" readonly type="text" value="浙江省/杭州市/拱墅区" data-toggle="city-picker">
						</div>
					</div>
				</div>
			</div>
			<div class="title_text">
				详细地址
				<input type="text" value="请填写详细地址" onFocus="if(value==defaultValue){value='';}" onBlur="if(!value){value=defaultValue;}">
			</div>
		</div>
		<div class="menages"><i></i>保险起期</div>
		<div class="basic manager-div margin-b5">
			<div class="title_text">
				保险起期
				<div class="demo">
					<div class="lie"><input id="beginTime" class="kbtn select-srea" placeholder="请选择保险开始时间" /></div>
				</div>
				<div id="datePlugin"></div>
			</div>
		</div>
		<div class="height44"></div>
		<div class="bottom-can">
			<a href="cancer_information.html">下一步</a>
		</div>
		<!--<div class="bottom-can"><input type="submit" class="cancer-submit" value="下一步" /></div>-->
		</form>
	</body>

</html>